Transcript In the name of God - Isfahan University of Medical Sciences

In the name of God
Judicious Antibiotic Therapy for
Upper Respiratory Tract Infections
in Pediatrics
Dr. Hamid Rahimi
Pediatric Infectious Disease Specialist
References
 Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract
Infections in Pediatrics – Pediatrics 2013
 Clinical Practice Guideline for the Diagnosis and Management of Acute
Bacterial Sinusitis in Children Aged 1 to 18 Years – Pediatrics 2013
 The Diagnosis and Management of Acute Otitis Media - Pediatrics 2013
 Clinical Practice Guideline for the Diagnosis and Management of Group A
Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of
America - Clinical Infectious Diseases 2012
 More than 1 in 5 pediatric ambulatory visits to a physician
result in an antibiotic prescription.
 As many as 20% of antibiotic prescriptions are directed
toward respiratory conditions for which they are unlikely to
provide benefit.
 Recent evidence shows that broad-spectrum antibiotic
prescribing has increased and frequently occurs when
either no therapy is necessary or when narrower-spectrum
alternatives are appropriate.
 Such overuse of antibiotics causes avoidable drug-
related adverse events, contributes to antibiotic
resistance, and adds unnecessary medical costs.
 This is compounded by the fact that few new
antibiotics to treat antibiotic-resistant infections are
under development.
 Principles of Judicious Antibiotic Prescribing for
Upper Respiratory Tract Infections in Pediatrics



Principle 1: Determine the likelihood of a bacterial infection
Principle 2: Weigh benefits versus harms of antibiotics
Principle 3: Implement judicious prescribing strategies
Principle 1: Determine the
likelihood of a bacterial infection
 Many aspects of the clinical history, symptoms, and signs of bacterial
URIs overlap with or mirror those of viral infections or noninfectious
conditions.
 In the specific cases of AOM, acute bacterial sinusitis, and pharyngitis,
there are well-established stringent criteria that aid in distinguishing
bacterial from nonbacterial causes.
Principle 2: Weigh Benefits Versus
Harms of Antibiotics
 If a bacterial infection is determined to be likely, the next step is to
compare the evidence about the benefits of antibiotic therapy for
each condition to the potential for harms.
 Relevant outcomes to consider for benefits include



Cure rate
Symptom reduction
Prevention of complications, and secondary cases
 Outcomes for harms include
 Antibiotic-related adverse events (eg, abdominal pain, diarrhea, rash),
 Clostridium difficile colitis
 Development of resistance
 Cost
Principle 3: Implement Judicious
Prescribing Strategies
 When evidence suggests that antibiotics may provide
benefit, several aspects of judicious prescribing
should be considered.




Selecting an appropriate antibiotic agent that treats the most
likely pathogens
Selecting the appropriate dose
Treating for the shortest duration required
Considering the role of observation and use of delayed
prescribing strategies.
Acute Otitis Media
Acute Otitis Media
 The most common infection for which antibacterial agents
are prescribed for children in the US
 1/3 of office visits to pediatricians
Key Action Statements 1
Diagnosis of AOM
 Acute purulent otorrhea is present and otitis externa has
been excluded
 Moderate to severe bulging of the TM
 Mild bulging of the TM and …


Recent (less than 48 hours) onset of ear pain (holding, tugging,
rubbing of the ear in a nonverbal child)
or
Intense erythema of the TM
Key Action Statements 1
Diagnosis of AOM
 Clinicians should not diagnose AOM in children who do not
have MEE (based on pneumatic otoscopy and/or
tympanometry).
Normal TM
Moderate Bulging
Severe Bulging
Signs of middle-ear inflammation
Mild bulging with intense
erythema of the TM
Established acute otitis media
Predictive value of combinations of otoscopic
findings in children with acute ear symptoms
Differential diagnosis
 Other conditions

Redness of tympanic membrane





Decreased or absent mobility of tympanic membrane




AOM
Crying
Upper respiratory infection with congestion and inflammation of the mucosa lining the entire
respiratory tract
Trauma and/or cerumen removal
AOM and OME
Tympanosclerosis
A high negative pressure within the middle ear cavity
Ear pain





Otitis externa
Ear trauma
Throat infections
Foreign body
Temporomandibular joint syndrome
Management
 NNT (Number Need to Treat)
NNT in AOM for
Antibiotic therapy vs. control groups
Overall
<2 y/o
≥2 y/o
8
7
10
Unilateral AOM
17
20
15
Bilateral AOM
5
4
9
Pain, Fever, or both
Otorrhea
3
Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for acute otitis media:
an individual patient data meta-analysis. Lancet. 2006;368(9545):1429–1435
NNT in AOM for
antibiotic therapy vs. control groups
 Antibiotics produced a small reduction in the number of
children with pain 2 to 7 days after diagnosis.
 They also concluded that most cases spontaneously
remitted with no complications (NNT = 16).
 Antibiotics were most beneficial in children younger than 2
years with bilateral AOM and in children with otorrhea.
Sanders S, Glasziou PP, DelMar C, Rovers M. Antibiotics for acute otitis
media in children [review]. Cochrane Database Syst Rev. 2009;(2):1–43
Observation Option OR Wait & See protocol
 Observation without use of antibacterial agents in a
child with uncomplicated AOM is an option for
selected children
In this protocol …
 Deferring antibacterial treatment of selected children for
48 -72 hrs & limiting management to symptomatic relief
Key Action Statements 3
Management of AOM - Antibiotic Rx
 The clinician should prescribe antibiotic therapy for …
 AOM (bilateral or unilateral) in children 6 months and older with
severe signs or symptoms
(ie, moderate or severe otalgia or otalgia for >48 hours, or Temp ≥
39°C)

Bilateral AOM in children younger than 24 months without severe
signs or symptoms.

AOM in infant ≤6 months old
Key Action Statements 3
Management of AOM – Observation vs. Antibiotic Rx
 The clinician should either prescribe antibiotic therapy or
offer observation with close follow-up based on joint
decision-making with the parent(s)/caregiver for


Unilateral AOM in children 6 months to 23 months of age without
severe signs or symptoms.
AOM (bilateral or unilateral) in children 24 months or older without
severe signs or symptoms.
Key Action Statements 3
Management of AOM – Observation vs. Antibiotic Rx
 When observation is used, a mechanism must be in place to
ensure follow-up and begin antibiotic therapy if the child
worsens or fails to improve within 48 to 72 hours of onset
of symptoms.
Observation
 Observation is only appropriate when …
Follow-up can be ensured and antibiotic therapy initiated if
symptoms persist or worsen
 Specific follow-up system i.e.
 Reliable parent / caregiver
 Convenient obtaining medications if necessary
Observation
 Antibiotics should be prescribed when the patient does not
improve with observation for 48 to 72 hours
 Adequate follow-up may include …
1 - A parent-initiated visit or phone contact if symptoms worsen or do
not improve at 48 -72 hrs
2 - A scheduled follow-up appointment in 48 -72 hrs
3 - Giving parents an antibiotic prescription that can be filled if illness
does not improve in this time frame. “wait-and-see prescription”
(WASP)
 Selecting Effective
antibiotic
Key Action Statements 4
Selecting Effective antibiotic
 Clinicians should prescribe amoxicillin for AOM when a
decision to treat with antibiotics has been made.
 Clinicians should prescribe an antibiotic with additional
β-lactamase coverage for AOM when child



Has received amoxicillin in the past 30 days
Has concurrent purulent conjunctivitis
Has a history of recurrent AOM unresponsive to amoxicillin.
Macrolides & Cefixime
 Macrolides, such as erythromycin and azithromycin, have
limited efficacy against both H influenzae and
S pneumoniae.
 Cefixime has limited efficacy against S pneumoniae
 In last AAP recommendation
for treatment of AOM.
not recommended
Ceftriaxone
 Although a single injection of ceftriaxone is approved by the US FDA
for the treatment of AOM,
 Results of a double tympanocentesis study (before and 3 days after single dose
ceftriaxone) suggest that more than 1 ceftriaxone dose may be required to
prevent recurrence of the middle ear infection within 5 to 7 days after the initial
dose.
Clindamycin
±
3rd Generation Cephalosporin
 Clindamycin alone (30–40 mg/kg per day in 3 divided doses) may be
used for suspected penicillin-resistant S pneumoniae; however, the
drug will likely not be effective for the multidrug-resistant serotypes.
 Clindamycin lacks efficacy against H influenzae.
Key Action Statements 4
Selecting Effective antibiotic
 Clinicians should reassess the patient if the caregiver
reports that the child’s symptoms have worsened or failed
to respond to the initial antibiotic treatment within 48 to 72
hours and determine whether a change in therapy is
needed.
Duration of therapy
 For children younger than 2 y/o and severe disease, a
standard 10-day course is recommended
 A 7-day course of oral antibiotic appears to be equally
effective in children 2 to 5 years of age with mild or
moderate AOM.
 For children ≥ 6 years of age with mild to moderate disease
5 -7 days is appropriate
Follow-up of the Patient With AOM
 There is little scientific evidence for a routine 10- to 14-day reevaluation
visit for all children with an episode of AOM.
 The physician may choose to reassess some children, such as young
children with severe symptoms or recurrent AOM or when specifically
requested by the child’s parent.
 Antibiotic therapy in
Treatment Failure
Microbiology of AOM
Predicted treatment failure rates based on PD breakpoints
for expected pathogens in low- or high-risk AOM
Predicted treatment failure rates based on PD breakpoints
for expected pathogens in low- or high-risk AOM
In daily clinical practice…
Amoxicillin - Clavul. 90mg/kg
Ceftriaxone ×1 – 3 dose
Clindamycin + Cefixime
Amoxicillin 90mg/kg
Azithromycin
Clarithromycin
Cefixime
Cotri-Erythro
Cefuroxime
Amoxicillin - Clavul.30mg/kg
Amoxicillin 30 – 45 mg/kg
For getting
a ratio of amoxicillin to clavulanate of 14:1
 Co-Amoxiclave + Amoxicillin
156/325
1/3
125/250
2/3
 Farmentin BD + Faramox
228/456
1/2
200/400
1/2
In daily clinical practice…
 Month of year ( mehr vs. farvardin)
 Previous antibacterial treatment
In daily clinical practice…
In daily clinical practice…
 Previous (First line) antibacterial treatment Failure
Amoxicillin
30mg/kg
Amoxicillin - Clavul.
90mg/kg
Azithromycin
Cefixime
Cotri-Erythro
Cefuroxime
Azithromycin
Clarithromycin
Cefixime
Cotri-Erythro
Cefuroxime
Amoxicillin - Clavul. 30mg/kg
Amoxicillin - Clavul. 90mg/kg
Amoxicillin 90mg/kg
Acute Bacterial Sinusitis
Scope of Problem
 3rd most common diagnosis for which antibiotics are
prescribed
 Abnormalities of the paranasal sinuses are common during
the course of an uncomplicated cold (up to 87%).
 Viral URIs

  secondary bacterial sinusitis
0.5 -2% in adults
&
5% in children
Classification of Bacterial Sinusitis
 Acute bacterial sinusitis (ABS)

Infection lasting < 30 days, symptoms resolve completely
 Subacute bacterial sinusitis

Infection lasting between 30-90 days, yet resolves completely
 Recurrent

Episodes of <30 days duration with intervals of 10 days without symptoms >3
episodes in a 6-month period, or >4 episodes in one year

Each episodes respond briskly to antibiotic therapy
 Chronic sinusitis

Symptoms lasting >90 days

Some guidelines add treatment failure + a positive imaging study
Factors Predisposing to Sinusitis
Mucosal Swelling
Mechanical Obstruction
Systemic Disorder
Choanal atresia
Viral upper respiratory tract infection
Deviated septum
Allergic inflammation
Nasal polyps
Cystic fibrosis
Foreign body
Immune disorders
Tumour
Immotile cilia
Ethmoid bulla
Local Insult
Facial trauma
Swimming, diving
Drug-induced rhinitis
Gastroesophageal reflux
Causative factors - URTI
 Approximately 60-80% of bacterial sinus infections
 Day-care centre should be as small and clean as possible
Causative factors - Allergy
 Approximately 15% of bacterial sinus infections
 80% of children with RS have a family history of allergy,
(general population 15% - 20%)
  50% of sinusitis is closely associated with asthma
  50% of children with chronic sinusitis have some element
of allergy
Causative factors - Allergy
 Allergy Should be considered in all children with …



A history of allergic signs and symptoms
(watery rhinorrhea, pruritus, sneezing, transverse nasal crease,
allergic shiners, frequent rashes)
Seasonal patterns of infection
Specific allergen reactions
(dust, pet dander, particular foods)

Strong family history of allergy or asthma
Causative factors - Airway pollutants
 Airway pollutants can have direct irritant effects on the
nasal and sinus mucosa.
 The most significant irritant in RS is environmental tobacco
smoke.
 Car exhaust, diesel fumes
 Cold air / Dry air
Viral Upper Respiratory Tract Infections
ABS Symptoms
 Persistent rhinorrhea
 Cough particularly is troublesome at night
 Occasionally vomiting
 Fever
 Periorbital swelling
 Malodorous breath
Physical Findings
 In general, the diagnosis of ARS depends on clinical presentation alone,
correlated with physical findings …

Mucopurulent nasal discharge

Anterior rhinoscopy with an otoscope

Highest positive predictive value

Swelling of nasal mucosa

Mild erythema

Facial pain (unusual in children)

Periorbital swelling

Malodorous breath
Key Action Statement 1
 Clinicians should make a presumptive diagnosis of
acute bacterial sinusitis when a child with an acute
URI presents with the following:

Persistent illness, ie, nasal discharge (of any quality) or daytime
cough or both lasting more than 10 days without improvement;
OR

Worsening course, ie, worsening or new onset of nasal discharge,
daytime cough, or fever after initial improvement;
OR

Severe onset, ie, concurrent fever (temperature ≥39°C) and
purulent nasal discharge for at least 3 consecutive days.
Differential diagnosis
 The main consideration is the distinction between viral URI
or allergic inflammation and secondary bacterial infection
of the paranasal sinuses.
 Others
 Allergic or non-allergic rhinitis with or without reactive
airways disease
 Nasal foreign body
 Pertussis
Key Action Statement 2A
 Clinicians should not obtain imaging studies
(plain films, CT, MRI, or ultrasonography) to
distinguish acute bacterial sinusitis from
viral URI.
Key Action Statement 2B
 Clinicians should obtain a contrast-enhanced CT
scan of the paranasal sinuses and/or an MRI with
contrast whenever a child is suspected of having
orbital or central nervous system complications of
acute bacterial sinusitis.
 Management
 Spontaneous resolution in 30 - 70% of children …
 Also high rate of spontaneous resolution in adults
 Meta-analysis of 9 DBT
 The NNT




For rhinosinusitis-like complaints was 15
For purulent discharge in the pharynx was 8
Patients who were older, reported symptoms for longer, or reported
more severe symptoms also took longer to cure but were no more
likely to benefit from antibiotics than other patients.
No clinical signs/symptoms that justify treatment even after 7-10
days of symptoms
Key Action Statement 3
 Initial Management of Acute Bacterial Sinusitis

“Severe onset & worsening course” acute bacterial
sinusitis. The clinician should prescribe antibiotic therapy
for acute bacterial sinusitis in children with severe onset or
worsening course (signs, symptoms, or both)
Key Action Statement 3
 Initial Management of Acute Bacterial Sinusitis

“Persistent illness.” The clinician should either prescribe
antibiotic therapy OR offer additional outpatient
observation for 3 days to children with persistent illness
(nasal discharge of any quality or cough or both for at least
10 days without evidence of improvement).
Key Action Statement 3
 Initial Management of Acute Bacterial Sinusitis

“Persistent illness” outpatient observation

Factors that might influence this decision include ….






symptom severity
the child’s quality of life
recent antibiotic use
previous experience or outcomes with acute bacterial sinusitis
cost of antibiotics, ease of administration
caregiver concerns about potential adverse effects of antibiotics,
persistence of respiratory symptoms, or development of complications.
Key Action Statement 3
 Initial Management of Acute Bacterial Sinusitis

“Persistent illness” antibiotic therapy in 1st visit if …




Children who received antibiotic therapy in the previous 4 weeks
those with concurrent bacterial infection (eg, pneumonia, suppurative
cervical adenitis, group A streptococcal pharyngitis, or acute otitis media)
those with actual or suspected complications of acute bacterial sinusitis
those with underlying conditions (asthma, cystic fibrosis,
immunodeficiency, previous sinus surgery, or anatomic abnormalities of
the upper respiratory tract)
Key Action Statement 3
Key Action Statement 4
 Clinicians should prescribe amoxicillin ± clavulanate as
first-line treatment when a decision has been made to
initiate antibiotic treatment of acute bacterial sinusitis.

For children aged 2 years or older with uncomplicated acute
bacterial sinusitis that is mild to moderate in degree of severity
who do not attend child care and who have not been treated with
an antimicrobial agent within the last 4 weeks, amoxicillin is
recommended at a standard dose of 45 mg/kg per day in 2 divided doses.

Patients presenting with moderate to severe illness as well as those
younger than 2 years, attending child care, or who have recently been
treated with an antimicrobial may receive high-dose amoxicillinclavulanate (80–90 mg/kg per day of the amoxicillin component
with 6.4 mg/kg per day of clavulanate in 2 divided doses with a
maximum of 2 g per dose).
Key Action Statement 4
 A single 50-mg/kg dose of ceftriaxone, given either intravenously or
intramuscularly, can be used for children who are vomiting, unable to
tolerate oral medication, or unlikely to be adherent to the initial doses
of antibiotic.
 If clinical improvement is observed at 24 hours, an oral antibiotic can
be substituted to complete the course of therapy. Children who are still
significantly febrile or symptomatic at 24 hours may require additional
parenteral doses before switching to oral therapy.
Key Action Statement 4
 The treatment of patients with presumed allergy to
penicillin …
 non–type 1 (late or delayed, >72 hours) hypersensitivity
reaction

Cefuroxime
 serious type 1 immediate or accelerated (anaphylactoid)
reaction



Cefuroxime OR
clindamycin (or linezolid) and cefixime
Levofloxacin
Key Action Statement 4
 Pneumococcal and H influenzae surveillance studies have indicated
that resistance of these organisms to Cotrimoxazole and
azithromycin is sufficient to preclude their use for treatment of
acute bacterial sinusitis in patients with penicillin
hypersensitivity.
 Second-and third-generation oral cephalosporins are no longer
recommended for empiric monotherapy of ABRS due to variable rates
of resistance among S. pneumoniae.
 Combination therapy with a third-generation oral cephalosporin
(cefixime) plus clindamycin may be used as second-line therapy for
children with non–type I penicillin allergy or from geographic regions
with high endemic rates of PNS S. pneumoniae
Key Action Statement 4
 The optimal duration of antimicrobial therapy for patients with acute
bacterial sinusitis has not received systematic study. Recommendations
based on clinical observations have varied widely, from 10 to 28 days of
treatment. An alternative suggestion has been made that
antibiotic therapy be continued for 7 days after the patient
becomes free of signs and symptoms.
Key Action Statement 5A
 Clinicians should reassess initial management if there is
either a caregiver report of worsening (progression of initial
signs/symptoms or appearance of new signs/symptoms) OR
failure to improve (lack of reduction in all presenting
signs/symptoms) within 72 hours of initial management.
Key Action Statement 5B
 If the diagnosis of acute bacterial sinusitis is confirmed in a
child with worsening symptoms or failure to improve in 72
hours, then clinicians may change the antibiotic therapy for
the child initially managed with antibiotic OR initiate
antibiotic treatment of the child initially managed with
observation.
No Recommendation (Adjuvant Therapy)
 Potential adjuvant therapy for acute sinusitis might include
intranasal corticosteroids, saline nasal irrigation or lavage,
topical or oral decongestants, mucolytics, and topical or
oral antihistamines.
 A recent Cochrane review on decongestants,
antihistamines, and nasal irrigation for acute sinusitis in
children found no appropriately designed studies to
determine the effectiveness of these interventions.
Pharyngitis
Incidence
 One of the most common complaint leading older
children and adults to acutely seek medical care
 10% of all general practice consultations
 2nd most common diagnosis in the pediatric age
group
Classification
 Nasopharyngitis
 Illness with nasal symptoms
 Mostly viral etiologies
 Pharyngitis or tonsilopharyngitis
 Illness without nasal symptoms
 Many etiologies
Causes
 Viral (70-80%)
 Group A beta-haemolytic streptococcus GAS
12 - 40% in children and 5 - 10% in adults
Nasopharyngitis
 Viral infections >>>
 During cold weather months
 Rhinorrhea and congestion may be more prominent than sore throat
 Only pharyngeal erythema
except adenovirus( follicular & exudative pharyngitis )
 Mild or no cervical adenopathy
 Lower respiratory tract & GI sign & symptoms
 Acute & self-limited ( 4 – 10 days)
Pharyngitis - 1
 Etiology
 Bacterial
Group A β-hemolytic streptococci
 Group C & G β-hemolytic streptococci
 Arcanobacterium haemolyticum
 Mycoplasma Pneumonia
 N. gonorrhea
 Corynebacterium diphteriae
 Anaerobes
…

Pharyngitis - 2
 Viral Causes
 Adenovirus
 Influenza & Parainfluenza Virus
 EBV
 Entrovirus
 Herpes virus
Pharyngitis - 3
 Non-infectious illness
 Aphthous stomatitis
 PFAPA
 Behcet syndrome
 Kawasaki disease
 Stevens-Johnson syndrome
GAS Pharyngitis
 15 – 30 % pharyngitis in pediatric BUT only 5- 10 % in
adults
 Prescription of antibiotics for pharyngitis in adults in
US

3/4 cases of pharyngitis
Clinical features associated with pharyngitis
 Clinical Scoring
6th Item Clinical Scoring System (1)
1) Age (5 to 15 years)
2) Season (late fall, winter, early spring)
3) Physical examination of acute pharyngitis
(erythema, edema, and/or exudates)
4) Tender, enlarged (>1 cm) Ant. cervical lymph nodes
5) Moderate fever (38.4º - 40º C)
6) No usual signs & symptoms of viral URTI
(i.e. cough, coryza, and nasal congestion)
6 Clinical Scoring System (2)
 If all 6 criteria
Throat culture 85 % positive for GAS
 BUT if even a single feature is absent …
predictive value of the streptococcal score falls to 50%
( No better than chance alone)
Pharyngitis – GAS
NOTE:
Only approximately 15% of all patients with GAS
pharyngitis have a classic presentation
So
It is impossible to diagnose streptococcal sore throat
on clinical grounds alone
Centor criteria
Centor criteria
 Tonsillar exudates
 Tender anterior cervical lymphadenopathy
 Absence of cough
 History of temperature of at least 38 0C
 In adults
  3criteria
75% sensitivity and 75% specificity versus culture
 Positive Predictive Value (PPV) is 40 - 60%


IF < 1-2 criteria

Negative Predictive Value ( NPV ) is 80%
Pharyngitis GAS - Laboratory Investigations
 Throat culture
 Rapid Antigen Tests (RAT)
 Anti-streptolysin O (ASO) titres
Pharyngitis – GAS
 Culture
Imperfect Gold standard for the diagnosis
Late, carrier vs. infection
 Rapid antigen detection test ( RADT )
Very specific, 80-90% sensitive
 Recommendation in children:
RADT as an initial screen
RADT is Positive
RADT is negative
Treatment
Throat culture
 Management
I. How Should the Diagnosis of GAS Pharyngitis Be
Established?
 Swabbing the throat and testing for GAS pharyngitis by rapid antigen
detection test (RADT) and/or culture should be performed because the
clinical features alone do not reliably discriminate between
GAS and viral pharyngitis except when overt viral features
like rhinorrhea, cough, oral ulcers, and/or hoarseness are
present.
 In children and adolescents, negative RADT tests should be backed up
by a throat culture . Positive RADTs do not necessitate a back-up
culture because they are highly specific .
I. How Should the Diagnosis of GAS Pharyngitis Be
Established?
 Routine use of back-up throat cultures for those with a negative RADT
is not necessary for adults in usual circumstances.
 Anti-streptococcal antibody titers are not recommended in the routine
diagnosis of acute pharyngitis as they reflect past but not current
events.
II. Who Should Undergo Testing for GAS
Pharyngitis?
 Testing for GAS pharyngitis usually is not recommended for children or adults
with acute pharyngitis with clinical and epidemiological features that
strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness,
and oral ulcers).
 Diagnostic studies for GAS pharyngitis are not indicated for <3 y/o.
 Follow-up post treatment throat cultures or RADT are not recommended
routinely but may be considered in special circumstances.
 Diagnostic testing or empiric treatment of asymptomatic household contacts of
patients with acute streptococcal pharyngitis is not routinely recommended.
‫آیا کودک دو سال به باال گلودرد دارد؟‬
‫آیا کودک موقع غذا خوردن مشکل دارد؟‬
‫• معاینه کنید‪:‬‬
‫اگر بله‪ ،‬سوال کنید‪:‬‬
‫• آیا کودک آبریزش بینی دارد؟ • حلق را از نظر قرمزی‪ ،‬پتشی و‬
‫اگزودا نگاه کنید‪.‬‬
‫• آیا کودک سرفه می کند؟‬
‫• آیا چشم های او قرمز است؟ • گردن را از نظر لنف آدنوپاتی‬
‫لمس کنید‪.‬‬
‫• آیا عطسه می کند؟‬
‫• دمای بدن کودک را اندازه گیری‬
‫• آیا خشونت صدا دارد؟‬
‫کنید‪.‬‬
‫طبقه بندی کنید‪:‬‬
‫• تب و دو نشانه از نشانه های زیر را داشته باشد‪:‬‬
‫( دو نشانه یا بیشتر از نشانه های ردیف سبز را نداشته باشد)‬
‫•‬
‫•‬
‫•‬
‫اگزودا در حلق‬
‫لنف آدنوپاتی قدامی گردن‬
‫پتشی‬
‫لوزه ها‬
‫قرمزی منتشر‬
‫نرم عضالنی تزریق کنید‪.‬‬
‫کام‪) 3-‬‬
‫روی‪3-6‬‬
‫سیلین (‬
‫نقاط پنی‬
‫نوبت بابنزاتین‬
‫‪‬یک‬
‫•‬
‫•‬
‫•‬
‫•‬
‫قرمزی چشم‬
‫سرفه‬
‫خشونت صدا‬
‫عطسه‬
‫گلو درد استرپتوکوکی ‪ ‬برای تب باال یا مساوی ‪ 38.5‬درجه استامینوفن بدهید‪.‬‬
‫• آبریزش بینی‪ ‬به مادر توصیه کنید که چه زمانی فورا برگردد‪.‬‬
‫دو نشانه از نشانه های زیر را داشته باشد‪:‬‬
‫• آبریزش بینی‬
‫• قرمزی چشم‬
‫• سرفه‬
‫• خشونت صدا‬
‫• عطسه‬
‫‪‬اگر در طبقه بندی دیگری قرار دارد اقدامات‬
‫گلودرد استرپتوکوکی‬
‫آن طبقه بندی را انجام دهید‪ .‬در غیر این‬
‫ندارد‬
‫صورت درمان عالمتی کنید‪.‬‬
III. What Are the Treatment Recommendations for
Patients With a Diagnosis of GAS Pharyngitis?
 Patients with acute GAS pharyngitis should be treated with an
appropriate antibiotic at an appropriate dose for a duration likely to
eradicate the organism from the pharynx (usually 10 days).
 Based on their narrow spectrum of activity, infrequency of adverse
reactions, and modest cost, penicillin or amoxicillin is the
recommended drug of choice for those non-allergic to these
agents.
 Treatment of GAS pharyngitis in penicillin-allergic individuals should
include a first generation cephalosporin (for those not anaphylactically
sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or
azithromycin for 5 days.
 With antimicrobial therapy, most throat cultures become
negative within 24 hours and it is presumed that the patient
is no longer contagious and may return to day care, school,
or work
IV. Should Adjunctive Therapy With NSAIDs, Acetaminophen,
Aspirin, or Corticosteroids Be Given to Patients Diagnosed
With GAS Pharyngitis?
 Adjunctive therapy may be useful in the management of
GAS pharyngitis.



If warranted, use of an analgesic/antipyretic agent such as acetaminophen or
an NSAID for treatment of moderate to severe symptoms or control of high
fever associated with GAS pharyngitis should be considered as an adjunct to
an appropriate antibiotic .
Aspirin should be avoided in children.
Adjunctive therapy with a corticosteroid is not recommended.
Common Cold,
Nonspecific URI,
Acute Cough Illness,
Acute Bronchitis
 Symptoms of the common cold, nonspecific URI, and
bronchitis may overlap with or mirror those of
bacterial URIs and can include cough, congestion,
and sore throat. Collectively, these viral conditions
account for millions of office visits per year.
 Acute bronchitis, in particular, is a cough illness that
is diagnosed during more than 2 million pediatric
office visits annually, and antibiotics are prescribed
more than 70% of the time.
 Application of diagnostic clinical criteria for AOM,
sinusitis, and pharyngitis should aid clinicians in
excluding these conditions.
 Management of the common cold, nonspecific URI,
acute cough illness, and acute bronchitis should
focus on symptomatic relief. Antibiotics should
not be prescribed for these conditions.
Thanks for your attention.